INSERT PHOTO IN MASTER SLIDE! …...A Review of Behavioral Economics in Reproductive Health. Berkeley, CA: CEGA. 4 JSI Research & Training Institute, Inc. (JSI) & ideas42. (2018)

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USING A BEHAVIORAL ECONOMICS APPROACH FOR

FAMILY PLANNING

October 2020

This brief is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Breakthrough ACTION and do not necessarily reflect the views of USAID or the United States Government.

LESSONS AND CONSIDERATIONS

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| 1Using a Behavioral Economics Approach for Family Planning: Lessons and Considerations

In light of both ambitious global family planning (FP) goals and the success of social and behaviorchange (SBC) programming in contributing to those goals, donors and implementers have been exploring ways to enhance the impact of behavior change interventions. SBC refers to activities or interventions that seek to understand and facilitate change in behaviors and the social norms and environmental determinants that drive them. SBC interventions are grounded in a number of different disciplines, including behavioral economics (BE). This brief highlights opportunities and recommendations for using BE to influence positive FP outcomes based on the existing evidence. There is a companion brief examining another approach of interest: human-centered design.

What is Behavioral Economics

The foundational principles of BE are that (1) human behavior is extremely complex, but often predictable, and (2) the context in which decisions and actions are made and taken greatly influences behavior. BE leverages insights from social psychology, economics, and other disciplines to understand why people do what they do.1

What is Social and Behavior Change?

Social and behavior change refers to activities or interventions that seek to understand and facilitate change in behaviors and social norms and environmental determinants that drive them. SBC interventions are grounded in a number of different disciplines, including social and behavior change communication, community mobilization, marketing, advocacy, BE, human-centered design, and social psychology.2

1 Darling, Matthew, Saugato Datta, and Sendhil Mullainathan. “The Nature of the BEast: What Behavioral Economics Is Not.” Center For Global Development. https://www.cgdev.org/publication/nature-beast-what-behavioral-economics-not (March 12, 2020).

2 High-Impact Practices in Family Planning (HIPs). Social and Behavior Change: A Critical Part of Effective Family Planning Programs. Washington, DC: USAID; 2018 Apr. Available from:https://www.fphighimpactpractices.org/wp-content/uploads/2018/12/SBC_Overview.pdf


Breakthrough ACTION compiled grey and peer-reviewed evidence on the impact of applying a BE approach within FP programming using the following key search terms:

We used the following search engines: Google Scholar, PubMed, and ProQuest. Literature was not limited by year or geographic region. Articles were excluded if they implemented an approach often associated with a BE strategy, such as text message reminders, but did not identify or use BE principles during their design and implementation phases.

Our review generated only six evaluations, indicating a nascent interest in applying BE; this means little evidence is available on its application within FP programs. Using the evidence that does exist, this brief identifies opportunities and recommendations for using a BE approach to influence positive FP outcomes. More details on the identified literature are included in the Evidence Snapshots in Appendix I.

Additionally, examples of recent programmatic applications of BE in FP were sourced directly from implementers, including Breakthrough ACTION. A brief survey was circulated to targeted relevant working groups to solicit implementation experiences. The results from this survey are included in Appendix II. The programmatic examples were not used to develop the evidence-based synthesis below.

Methodology

• Impact

• Outcome

• Process

• Family Planning

• Contraception

• Behavioral Science

• Reproductive Health

• Behavioral Economics

• Behavioral Insights

• Nudge

• Heuristic


A BE approach is appropriate for addressing judgement and decision-making biases that influence intention formation and intention-action gaps. A lack of intention formation—not deciding to practice a behavior—could take the form of an individual who wants to avoid pregnancy yet has not decided to use a contraceptive method. An intention-action gap refers to situations when an individual has decided to act but then does not follow through on this intention. This could be a provider who has the skills and intent to provide quality FP counseling but does not consistently give quality counseling in reality. Another example is an individual who decided to use a contraceptive method to avoid an unintended pregnancy but does not consistently take the method per its indications.

When to Use a Behavioral Economics Approach in Social and Behavior Change Programs

Address an absence of intention to practice a given behavior or a gap between intention formation and practicing the behavior

BE is focused on understanding the specific context—physical, social, and otherwise—in which individuals make decisions. In this way, BE can be applied to inform interventions for a wide range of different populations since the focus is on the context rather than on the individual. The interventions identified in the literature illustrate BE’s applicability to FP challenges for a diverse set of populations, including both provider behavior change as well as subpopulations of FP clients, such as postpartum women or post-abortion clients.

2 Target diverse populations

1


BE leverages research on human behavior to develop a nuanced understanding of the behavioraldrivers of the problem. A BE approach can be useful when a program has a clear desired behavioraloutcome (such as continuation of contraceptive use), but program designers do not fully understand either what is preventing progress on that outcome or when previous strategies have been unsuccessful. Behavioral barriers highlighted in the literature reviewed include the following:

• Present bias: The tendency to favor immediate rewards at the expense of long-term rewards

• Salience: The prominence of a person, object, or experience compared to other elements in the environment

• Scarcity: A context of not having enough of a key resource, including time, which negatively impacts cognition, decision-making, and self-control in individuals’ actions and decision-making

• Emotion and rationality: The roles of “hot” (emotional) states and “cold” (rational) states in FP decision-making

An example may be a postpartum client who wants to avoid a subsequent pregnancy; however, since that future pregnancy is not on her mind during the postpartum visit, she does not adopt a FP method.

When to Use a Behavioral Economics Approach in Social and Behavior Change Programs

Deepen understanding of behavioral drivers and barriers to practicing a behavior from a different perspective

BE focuses on addressing the context that shapes how individuals make FP decisions and take actions. This context includes the information and messages they are exposed to, the interactions they have with other people, and the physical environment, among other factors. From a BE perspective, changing the context could translate to adding a deadline to help overcome the temptation to procrastinate adoption of a FP method, or highlighting information that might not be top-of-mind at a relevant moment, or making a provider’s peers’ behavior more visible, which then allows providers to evaluate their own performance.

4 Redesign the underlying context which shapes how decisions are made and actions are taken

3


While there has been interest in using a BE approach within FP programming,3 given its relatively recent application in the field there is still limited literature using experimental methods to evaluate its impact. We need more evidence to better understand when using a BE approach may be most appropriate. The studies identified were all published in the last four years, with a majority of them published within the last two years; this suggests that, while limited, research on the application of BE within FP programming is on the rise. This nascent evidence base illustrates that BE approaches can be effectively used to address a diverse set of FP outcomes among different populations, for example, from husbands’ support for contraceptive use to consistent FP counseling by providers.

Things to Consider When Using Behavioral Economics for Family Planning

Limited evidence base demonstrating the application of BE within FP

In considering a BE approach or design, implementers should consider how designs aimed at addressing behavioral barriers will require certain behaviors from the individuals who are implementing them. In an example reviewed below, implementers found designs were more successful if they were seamlessly integrated into existing processes and systems rather than creating additional reporting mechanisms.4 As with any other design approach, considering design implications within current contexts and constraints is vital when implementing solutions informed by a BE approach.

2 Behaviors required for successful implementation in the design of behavioral solutions

As global health professionals continue to face a persistently high unmet need for FP in many settings, a BE approach may be particularly valuable in developing critical insights, reframing issues, and supporting the development of new approaches. Implementers can revisit programs and approaches that have not found a lot of traction and apply a BE approach to understand how the context influences behavior. This, in turn, informs the creation or refinement of innovative solutions to address the behavioral challenges contributing to unmet need.

3 Review of existing programs and approaches for developing new insights or ways to address unmet need

3 Ashton, L., et al. (2015). A Review of Behavioral Economics in Reproductive Health. Berkeley, CA: CEGA.

4 JSI Research & Training Institute, Inc. (JSI) & ideas42. (2018). A Behavioral Economics Approach to Reduce the Injectable Contraceptive Discontinuation Rate in Ethiopia: A Stratified-Pair, Cluster-Randomized Field Study. The Last Ten Kilometers Project 2020 (L10K 2020), JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia and Arlington, VA, USA; and ideas42, New York, NY, USA: JSI and ideas42.

1


ZambiaResearchers studied how information asymmetry regarding maternal mortality and morbidity influences differences between men’s and women’s fertility preferences and how this difference in preference may affect adoption of contraception. Drivers of men’s fertility preferences are not well understood; researchers hypothesized that men do not fully recognize the costs and risks of childbearing because they have fewer opportunities to learn about the risks. Researchers invited couples to gender-specific community workshops and shared FP education with all participants. In one study arm, only husbands received information on maternal mortality and morbidity; in another arm, only wives received this information.

AppendicesAppendix I: Evidence Snapshots

“How education about maternal health risk can change the gender gap in the demand for family planning in Zambia”5

In couples where the husband received information on maternal mortality, the probability of pregnancy decreased within a year of the intervention. These same husbands were also less likely to report wanting another child. Among men in the treatment group, there was suggestive evidence of an increase in oral contraceptive adoption by the couple. Findings around couples’ communication, however, were mixed. Husbands who received the maternal mortality information were more likely to report that they tried to convince their spouse to use FP but also reported a decrease in the probability of agreement on contraceptive use. The intervention had no effect on demand for children among women.

5 Ashraf, N., Field, E., Voena, A., & Ziparo, R. (2019). How education about maternal health risk can change the gender gap in the demand for family planning in Zambia, 3ie Impact Evaluation Report 104. New Delhi: International Initiative for Impact Evaluation (3ie). https://doi.org/10.23846/OW3IE104

Impact


South AfricaResearchers were interested in increasing women’s practice of dual protection (the use of a barrier method to prevent HIV in addition to a contraceptive to prevent pregnancy) among post-abortion clients. Researchers suggested that the decisions to use a long-acting reversible contraceptive (LARC) and to use condoms are made during different emotional states (“cold” and “hot” states, respectively). The design established a lottery for a small monetary prize for post-abortion care clients who returned for care and who were practicing dual protection at a six-month follow-up visit. Researchers hypothesized that a lottery would “counterbalance the different weights given to the [contraceptive] decisions in different hot/cold states.”


“The Empower Nudge lottery to increase dual protection use: a proof-of-concept randomised pilot trial in South Africa”6

Participants in the lottery group were six times more likely to return at a three-month visit and five times more likely to return for the six-month visit than participants in the control group. Participants were also three times more likely to use dual protection at three months than non-participants, though there were no significant findings at the six-month visit.

6 Galárraga, O., Harries, J., & Maughan-Brown, B. et al. (2018). “The empower nudge lottery to increase dual protection use: A proof-of-concept randomised pilot trial in South Africa.” Reproductive Health Matters, 26(52), 1510701. https://doi.org/10.1080/09688080.2018.1510701

Impact


United StatesResearchers hypothesized that relying on condoms to avoid pregnancy is a less effective method because the decision to use them occurs when individuals are more likely to make impulsive choices. The study designed an intervention to encourage the adoption of non-condom methods and reduce barriers associated with method adoption, such as unnecessary physical exams or waiting for a follow-up visit to receive the method, to increase initiation and continuation of contraception. The intervention had two components:

1. Introduction of the World Health Organization’s decision-making tool for FP clients and providers

2. Providing financial incentives for clients who attended follow-up visits to help ensure contraception continuity

The intervention was delivered in a clinic co-located in an opioid maintenance clinic to reduce barriers to uptake.


“Using behavioral economic theory to increase use of effective contraceptives among opioid-maintained women at risk of unintended pregnancy”7

7 Heil, S. H., Hand, D. J., & Sigmon, S. C., et al. (2016). Using behavioral economic theory to increase use of effective contraceptives among opioid-maintained women at risk of unintended pregnancy. Preventive Medicine, 92, 62–67. https://doi.org/10.1016/j.ypmed.2016.06.023

While the study was limited by the small number of participants (n=31), the study showed that contraception initiation was significantly higher among participants in the treatment group and that prescription contraceptive continuation was significantly higher at the one-, three- and six-month mark among the treatment group as compared to the control.

Impact


EthiopiaResearchers suggested that people who are experiencing a state of scarcity are more likely to focus on the most urgent needs related to the resource that is scarce. This can pose particular challenges for contraceptive continuation. Researchers found that clients often discontinue contraception because they (1) fail to remember to return for subsequent injection visits; (2) focus on the exact date of the appointment and do not have alternative plans if unable to return on that exact date; and (3) perceive a limited choice set and want to reduce side effects but do not consider alternative methods when experiencing side effects. Providers also have limited bandwidth to track and manage clients. Researchers designed timely reminders for women through client appointment cards, a health extension worker planning calendar to serve as an aid in scheduling future appointments and client outreach, and a client counseling job aid.


“Application of behavioral economics principles to reduce injectable contraceptive discontinuation in rural Ethiopia: A stratified-pair, cluster-randomized field trial”8

“A Behavioral Economics Approach to Reduce the Injectable Contraceptive Discontinuation Rate in Ethiopia: A Stratified-Pair, Cluster-Randomized Field Study”9

8 Karim, A. Guichon, D., Yihun, B., et al. (2019). Application of behavioral economics principles to reduce injectable contraceptive discontinuation in rural Ethiopia: A stratified-pair, cluster-randomized field trial. Gates Open Research, 3, 1494. https://doi.org/10.12688/gatesopenres.12987.2

9 JSI Research & Training Institute, Inc. (JSI) & ideas42. (2018). A Behavioral Economics Approach to Reduce the Injectable Contraceptive Discontinuation Rate in Ethiopia: A Stratified-Pair, Cluster-Randomized Field Study. The Last Ten Kilometers Project 2020 (L10K 2020), JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia and Arlington, VA, USA; and ideas42, New York, NY, USA: JSI and ideas42.

Clients in the intervention group were less likely to discontinue injectables within 12 months of uptake. Clients were also able to recall more side effects for injectable contraceptive methods in the intervention group, suggesting that the client counseling job aid may have improved provider counseling.

Impact


KenyaResearchers recognized that existing programs focused on reducing financial barriers to increase postpartum FP use were not sufficient and that a behavioral approach may be successful. Researchers suggested that, given competing priorities during the postpartum period, a future pregnancy is not “‘top of mind” for women. Researchers tested two behavioral nudges in addition to a free contraceptive voucher program: the introduction of a deadline to use the voucher within two months and a short message service (SMS) reminder. The designs were informed by evidence that introducing a deadline increases the likelihood of completing an action and that sending reminders increases appointment and medication adherence.


“Free contraception and behavioural nudges in the postpartum period: evidence from a randomised control trial in Nairobi, Kenya”10

10 McConnell, M., Rothschild, C. W., Ettenger, A., et al. (2018). Free contraception and behavioural nudges in the postpartum period: evidence from a randomised control trial in Nairobi, Kenya. BMJ global health, 3(5), e000888.

The probability of using a modern contraceptive method for those that received the SMS reminder in addition to the standard voucher was higher than those in the control group (standard voucher only) at 22 weeks postpartum. While none of the interventions had a significant impact on the likelihood of using modern contraception at nine weeks postpartum, findings suggest that the SMS alone also led to a large increase in the probability of accepting a FP method at 22 weeks. The deadline voucher (which expired within two months) did not affect the uptake of FP. The most commonly adopted method using the voucher was the implant, followed by injectables and contraceptive pills.

Impact


NepalWhile researchers found that providers were well-informed of best practices related to FP counseling and method provision and were motivated to provide quality services, adoption of LARCs by post-abortion clients remained low. Researchers found that providers were not consistently able to assess their own performance and identify whether there was room for improvement. Providers also shared responsibilities with colleagues and may have assumed that others were providing comprehensive counseling. To address these factors, researchers designed posters which allowed providers to compare their facilities’ rates of LARC uptake to other similar health centers.


“Using Behavioral Science to Design a Peer Comparison Intervention for Postabortion Family Planning in Nepal”11

“The Effect of a Group Peer Comparison Intervention on Long-Acting Reversible Contraception Uptake: Experimental Evidence from Nepal”12

11 Spring, H., Datta, S., & Sapkota, S. (2016). Using behavioral science to design a peer comparison intervention for postabortion family planning in Nepal. Frontiers in Public Health, 4. http://journal.frontiersin.org/Article/10.3389/fpubh.2016.00123/abstract (June 14, 2017).

12 Barofsky, Jeremy T., et al. (2018). Evidence for a Behavioral Approach to Increase Long-Acting Contraception Uptake Among Post-Abortion Clients in Nepal: Experimental Results of a Peer Comparison Feedback Tool for Service Providers. https://appam.confex.com/appam/2018/webprogram/Paper28133.html

The study found clients in treatment facilities were more likely to adopt LARCs post-abortion. This was primarily driven by a shift from short-acting to long-acting methods rather than an increase in overall uptake.

Impact


The examples below demonstrate additional insights from applying a BE lens to FP programming. The programmatic examples reinforce many of the learnings described in the literature cited previously.

AppendicesAppendix II: Current Projects Using BE Elements

Country(ies) Project Name and Dates

Implementing Partners

Project Description Project Findings Insights

Bangladesh, Ethiopia, and Burkina Faso

(re)solve

(2017–2020)

Pathfinder International, Camber Collective, ICRW, and ideas42

Bangladesh: Marie Stopes Bangladesh, Shukhi Jibonproject, Ministry of Health and Family Welfare

Ethiopia: Transform: Primary Health Care project, Ministry of Health

Burkina Faso: Project Yam Yankré, Ministries of Health and Education

The project aimed to understand what stops women and girls in the developing world from using modern contraception to avoid unintended pregnancy in order to accelerate contraceptive uptake.

In Bangladesh, the project focused on supporting female garment factory workers in avoiding unintended pregnancy. To address the behavioral barriers identified, the project designed a planning prompt for pill users, an enhanced pill pack and supportive communication for side-effect management or switching methods, and an interactive digital training for providers for case-based counseling.

In Ethiopia, the project focused on increasing postpartum women’s uptake of modern contraceptive methods. To address the behavioral barriers identified, the project designed a planning prompt to be used during ANC visits, a provider

Low perceived pregnancy risk was found to be a barrier to contraceptive uptake among postpartum women in Ethiopia and adolescent girls in Burkina Faso.

Many projects often use a more traditional knowledge-based strategy, informing women they are at risk. (re)solve’s behavioral approach led to the development of alternate strategies to increase risk perception. For instance, in Burkina Faso, girls repeatedly felt the risk of pregnancy through scenarios in the board game. In the case of Ethiopia, postpartum women were screened for FP counseling need and informed of their pregnancy risk, using a familiar color scheme for health risks, in each newborn vaccine visit.

In Bangladesh, the project identified that many urban women were skipping pills on purpose in an effort to reduce side effects like nausea and

BE was an effective approach to employ in these three countries with diverse populations and different behavioral challenges. For one, the underlying context was clearly shaping how young girls and pregnant women were perceiving their pregnancy risk and in turn their intention to use contraceptives. The experiential and repeated nature of the approaches employed were different than other approaches in that they sought to change this context.

In Bangladesh, much work had been conducted on contraceptive uptake, but a deeper understanding of behavioral drivers and barriers from a different perspective allowed the team to identify that, rather than an intention problem, the challenge was instead a gap between an intention to use and consistent use. Furthermore, the team considered how the context of garment workers was driving inconsistent use of the pill in





Bangladesh, Ethiopia, and Burkina Faso(continued)

(re)solve

(2017–2020)

counseling sheet, a referral card completed before or during a child’s immunization visit, and a home visit tracking tool for health extension workers to follow up with postpartum women.

In Burkina Faso, the project focused on the uptake of contraceptives amongst unmarried girls in school. To address the behavioral barriers identified, the project designed a facilitated board game played in the classroom as well as several health facility-based designs: a health facility passport for girls to encourage facility visits; branded posters for the health facility; and branded nametags for health workers at the facility to indicate their commitment to providing youth-friendly services.

headaches. Leveraging this deeper understanding of the reasons behind this behavior, the project focused on providing and making alternative ways to manage contraceptive side effects salient.

order to reshape that context by employing a variety of solutions where women lived and worked.

Many projects on provider behavior and FP focus on ensuring that providers explain all methods, but they do not typically focus heavily on how they explain each method. Using a behavioral approach, the project was able to identify and address the potentially outsized effect that framing can have in how clients weigh options and select a method.






Malawi Breakthrough ACTION

(2018–2020)

Malawi Ministry of Health, Organized Network of Services for Everyone’s (ONSE) Health Project, Management Sciences for Health (MSH), ideas42

The project aimed to develop strategies that expand access to and uptake of modern contraceptive methods, particularly amongst postpartum clients, by changing the behavior of service providers in primary health care facilities. To address the behavioral barriers identified, the project designed an ANC health passport insert to prompt discussion of FP, a gamified group counseling tool to ensure providers provide comprehensive, unbiased information on all FP methods, a method referral card and referral tracking system, and a values clarification workshop for providers that serves as an introduction to the other project designs and an opportunity to discuss FP counseling.

The project team found that providers present inconsistent information on the advantages and disadvantages of each FP method during health talks. Clients and providers are influenced by the tendency to more easily recall methods which are most commonly used and discussed; clients were most likely to request information on methods they have heard of, and providers were most likely to discuss methods that they administer often. Providers relied on clients to determine which methods they would discuss during counseling. Additionally, guidance on FP counseling was centered around a method’s maximum duration of effectiveness rather than factors that were most important to the client such as return to fertility and what the method requires of the client.

BE was employed in this project given a need to deepen understanding of behavioral drivers and barriers from a different perspective. By exploring the underlying context in which providers counsel and women choose methods, the project was able to identify opportunities for improvement in provider behavior that would increase client method satisfaction and continuation. Furthermore, the team was able to consider solutions for intention formation challenges as well as gaps between intention and behavior for providers.






Zambia Breakthrough ACTION (2018–2020)

Zambia Ministry of Health, ideas42, CCP, ThinkPlace, Society for Family Health Zambia

The project aimed to develop strategies that expand HIV testing and condom use for men and adolescents engaging in risky behaviors and that increase uptake of modern contraceptive services among adolescents by changing the behavior of service providers in primary health care facilities. To address the behavioral barriers identified, the project designed a privacy and confidentiality refresher training for health providers and health facility staff, a confidentiality pledge to be signed (voluntarily) by all health providers, badges for health providers indicating their commitment to confidentiality, a client-provider promise to be displayed in providers’ offices and read aloud at the beginning of each consultation, and large branded display plaques placed on the outside of the facility to signal its commitment to confidentiality.

The project team found that adolescents do not seek FP, condoms, or HIV testing from health centers because they are concerned about privacy and confidentiality. Additionally, provider attitudes towards offering adolescent FP vary among providers and by the type of client seeking services. Many providers do not receive any training in youth-friendly services, and they do not tailor FP counseling specifically to youth.

BE was employed in this project to successfully design an intervention package to address the needs of diverse populations with different behavioral challenges across multiple health areas. The application of BE allowed the team to redesign elements of the context, providing several cues for service providers to adhere to their confidentiality pledges when interacting with their patients.






Senegal Behavioral Insights for Family Planning/ Reproductive Health

(2014–2019)

IntraHealthInternational, Ministry of Health and Social Action, ideas42

The project focused on designing a behaviorally-optimized solution to integrate FP services into child immunization days at health posts in Senegal. To address the behavioral barriers identified, the project reframed immunization days as “Family Health Days,” launched a mobile health drama for clients and an IVR mobile training course for health workers, and designed a referral card with integrated, age-relevant messaging on three complementary health behaviors to be given to women during immunization services.

The project team found that health workers had a narrow view of the purpose of integrated “immunization days” that led them to prioritize immunizations over other postpartum services. Additionally, no cues were available to help providers remember to discuss FP during this vital moment; to address this barrier, the project introduced cues in the referral cards to remind providers to discuss FP.

BE was employed to address lack of intention to provide FP counseling among immunization providers and follow-through on that intention. Furthermore, the application of BE allowed the team to redesign elements of the context, reframing the integrated health services and providing cues for health workers to discuss FP with clients.

Senegal Neema

(2016–2019)

IntraHealthInternational, Ministry of Health and Social Action, ideas42

The program sought to address unmet need among unmarried young people in Senegal who do not want to become pregnant yet do not use contraceptives.

To address the behavioral barriers identified, the project team designed a preventative care visit (a “Wellness Check-Up”) at health facilities for adolescents to provide a channel for uptake of contraceptives.

The project team found that youth often avoided making a decision about contraception because thinking about contraceptive use provoked negative associations with a negative identity. The team also found that youth were overconfident in their ability to avoid pregnancy through traditional or folk methods while overestimating the social and health risks of modern contraceptive methods.

BE was an effective approach to employ since it allowed the project to address an absence of intention to use contraceptives among youth and deepen the understanding of the behavioral drivers and barriers inhibiting intention formation. Furthermore, given the unique context in which youth make decisions, the project was able to redesign the context, in this case the facility context, which was shaping how youth perceived contraceptive use.






Uganda d-BIAS

(2017–2021)

Marie Stopes International, Marie Stopes Uganda, IntraHealthInternational, ideas42

The projects under d-BIAS aim to expand the application and adoption of behavioral science across the FP and reproductive health sector in order to improve the health and wellbeing of women of reproductive age worldwide.

The first d-BIAS project aims to reduce unmet need among postpartum women in Eastern Uganda. To address the behavioral barriers identified, the project designed an interactive game played by male partners of postpartum women, which highlights child spacing considerations in terms that resonate with men and builds confidence in discussing FP. A FP planning card given at the conclusion of the game encourages couples to discuss child spacing and to visit a health facility. After the game is completed, players, village health teams who facilitated the game and health providers receive reminders and encouragement by SMS.

The project team found that men underestimate the monetary cost of having children because they do not fully consider the costs until after the child is born. The underestimation of costs may be exacerbated by an assumption that some of their children will not survive, which is grounded in historically higher child mortality rates and in personal experiences of the early death of their own siblings. This tendency to overestimate the likelihood of something occurring—because we can easily recall it happening to ourselves or someone else—can lead men to underestimate the importance of spacing their children.

The BE approach provided insight into how men’s estimation of cost and risk is shaped by their context, through their own personal experiences and those of their community, ultimately contributing to a lack of intention to use FP. Through an interactive game to help men experience costs and risks and the role FP can play for them, the project reshaped the context to provide additional cues that help them to make choices with a more accurate perception of the costs and risks.






Uganda d-BIAS

(2017–2021)


The second d-BIAS project aims to reduce unmet need for contraceptives among adolescents in Uganda. To address the behavioral barriers identified, the project designed a “refer-a-friend” program used by young satisfied users or recipients of FP counseling, a counseling poster that displays “refer-a-friend” cards to show that other girls use them, a waiting room poster that advertises providers’ commitment to providing adolescent clients with the quality that they value, and staff nametags that welcome youth to the clinic.

The project team identified that many adolescent girls do not think of FP as “for girls like me.” The refer-a-friend program prompts girls to have conversations about FP, and the cards show multiple reasons a girl may choose to use FP. The cards (which have no identifying information) are hung in clinics, reinforcing the message that FP is for girls.

The BE approach was employed to address a lack of intention to use FP that was rooted in perceptions of who can and should use FP. By encouraging conversations between girls and offering clear, personal examples of reasons girls may choose to use FP, the project reshapes the context in which girls think about whether FP may be right for them.



Cover photo credit:

Jonathan Torgovnik/Getty Images/Images of Empowerment




Uganda d-BIAS

(2017–2021)


The third d-BIAS project employscommunity- and facility-based interventions delivered through mobile outreach channels that respond to concerns that LARC users have about their methods, with the aim of reducing unmet need for FP and reducing discontinuation of FP methods. To address the behavioral barriers identified, the project designed a referral card that indicates the service clients want to receive to streamline counseling and highlight alternative service options for clients with side effects, a side-effect response tool to empower community mobilizers to respond to clients’ concerns about side effects, and an FP Facts flipchart for providers and community mobilizers to combat common myths about LARCs.

The project team found that myths about LARCs and their side effects were the underlying reason that many women chose to remove their method. In rural settings, women frequently turned to community-based mobilizers for information, guidance, and reassurance. Not knowing how to respond, mobilizers directed clients to outreach clinics, which visit rural areas only infrequently. While they waited, clients’ fears and intentions to remove the method solidified. The project materials supported mobilizers in responding to concerns, helping to assuage fears, and directing clients to the services they need.

The project’s approach was based in a nuanced understanding of the drivers of discontinuation and the role that community-based mobilizers can play as trusted sources of guidance while clients wait for clinic services to become available. By assuaging misplaced fears about LARCS before clients go to the clinic, clients may be less intent on discontinuing and more receptive to counseling, side effects management, or switching when they are able to visit a clinic.


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INSERT PHOTO IN MASTER SLIDE! …...A Review of Behavioral Economics in Reproductive Health. Berkeley, CA: CEGA. 4 JSI Research & Training Institute, Inc. (JSI) & ideas42. (2018)